Rounds PREVIEW: The High-Performance Emergency Department

Sayah and his team did a top-down assessment of the ED flow and found multiple bottlenecks at CHA's three Massachusetts EDs in Cambridge, Somerville, and Everett, which together saw 96,712 ED visits in FY 2010 and 97,381 ED visits in FY 2011. It was not an ED capacity problem, they found, as there was plenty of ED bed capacity. Too many steps were happening consecutively that did not need to. CHA undertook a reengineering of its patient flow process, resulting in huge improvements in patient satisfaction and other key metrics in just six months.

The first step was eliminating traditional triage and registration. CHA hired "patient partners," multilingual nonclinicians whose role is to greet ED patients when they walk in the door and collect three pieces of information: name, identifier such as Social Security number or date of birth, and chief complaint. Answers are entered by the patient partner into a "computer on wheels" and CHA's Epic-based electronic health record. The process takes approximately two minutes. "With those three questions, the patient is registered; they are in the computer, I can take care of them in the ED, and they're brought right in," Sayah says.

The next step is the merger of what used to be registration, triage, and what was called express care into rapid assessment. The patient partner brings the patient directly into a room in the rapid assessment area. The patient is seen by a nurse and usually an ED tech first, says Lisa Kingsley-Rocker, RN, BSN, emergency department nurse manager at CHA's Whidden Hospital campus in the densely populated, working-class city of Everett, adjacent to Boston. Triage ranks the patient according the AHRQ Emergency Severity Index score of acuity from 1 to 5, with 1 being the most acute and 5 the least.